Interventional radiology placement of twin Tesio catheters for dialysis access: review of 75 patients.

PURPOSE: To evaluate the safety and efficacy of modern interventional radiology techniques and imaging guidance for placement of jugular vein twin Tesio hemodialysis catheters. MATERIALS AND METHODS: Eighty-two sets (75 patients) of twin Tesio catheters were percutaneously placed in the right (n = 70) and left (n = 12) internal jugular veins with use of ultrasound (US) and fluoroscopic guidance. Immediate procedural and late complications were recorded. The efficacy of the Tesio system was also evaluated. RESULTS: With US and fluoroscopic guidance, the technical success for access and catheter placement was 100%. Measured dialysis blood flow rate of greater than 375 mL/min was obtained in 95% of the patients and recirculation averaged 4.6% +/- 5%. An inadvertent common carotid artery puncture occurred in one (0.6%) patient and prolonged exit site bleeding occurred in another five patients (3%). Each of these was successfully controlled with compression. More chronically, catheter thrombosis and exit site infection occurred each at the rate of 0.16 episodes per 100 catheter days. All thrombosis and exit site infections responded to local thrombolysis and antibiotic therapy, respectively. Bacteremia occurred in 20 patients and required catheter removal in five patients. There was no clinical evidence of upper extremity or superior central vein thrombosis. CONCLUSION: Placement of internal jugular, twin Tesio catheters with use of imaging and interventional techniques provides a safe and efficacious means of either short or long-term hemodialysis.

Sonographic guidance when using the right internal jugular vein for central vein access.

OBJECTIVE: The intent of this study was to substantiate the advantages of the use of sonographic guidance for central venous access via the right internal jugular vein. SUBJECTS AND METHODS: Eighty sequential patients requiring central vein access were examined with a hand-held sonography transducer to determine the size, patency, and location of the right internal jugular vein before puncture. Access to the right internal jugular vein was subsequently performed, under sterile conditions, using sonographic guidance. Periprocedural complications were prospectively recorded. Subsequently, we compared our findings with published reports of complications when visible and palpable anatomic landmarks were used for guidance during cannulation of the internal jugular vein. RESULTS: Among these 80 patients, the anatomy of the right internal jugular vein was typical in only 57 (71%). In another 13 patients (16%), sonography showed a medial position of the right internal jugular vein, anterior to the common carotid artery. In three other patients (4%), the right internal jugular vein was positioned laterally by more than 1 cm. In the remaining seven patients (9%), the vein was thrombosed. Its diameter, measured without use of the Valsalva maneuver, also varied, measuring 0.5-2.0 cm. Cannulation was achieved in all 73 patients with a patent right internal jugular vein. One puncture was required in 68 patients (93%); two punctures in three other patients (4%); and three punctures in the remaining two patients (3%). In no case was the common carotid artery inadvertently punctured. Only one periprocedural complication occurred, and it was unrelated to the use of sonographic guidance. CONCLUSION: Sonographic guidance for central vein access via the right internal jugular vein is safer and more efficient than the traditional landmark approach.

Acute open-chest complete heart block by transeptal electrocoagulation.

A method of producing complete heart block (CHB) in open-chest dogs is described. Having found previous methods unreliable in our hands or excessively complex for the acute open-chest setting, we constructed an electrocautery pinch-clamp device that functions in both locating and destroying the area of the atrial septum that contains the atrioventricular node and His bundle. Fifteen male mongrel dogs were anesthetized with alpha-chloralose, intubated, and ventilated (Harvard 607). Through a left thoracotomy at the fifth intercostal space, the two arms of the clamp are introduced into the left and right atria, respectively, via the atrial appendages. The correct site for electrocautery is located by gently squeezing the atrial septum between the arms of the clamp. Systematic testing of the region of the septum that lies, roughly, between the coronary sinus ostium and the anterior portion of the septal leaflet of the tricuspid valve will result in a rhythm disturbance when the correct site is squeezed. Sustained pressure will yield overt dissociation of the atrial and ventricular contractions. The electrocautery current is then activated for 10-15 s. Lead II of the electrocardiogram is monitored, and if CHB is not sustained after 5 min, the procedure is repeated. Once CHB is established, the clamp is removed and the atrial defects are ligated. By application of this method with no prior use of the technique, 12 of 15 attempts produced stable CHB lasting at least 3-4 h. Examination of the hearts of eight of the animals revealed no septal defects or damage to the tricuspid valve. We conclude that this method offers significant advantages for the production of CHB in acute studies in the dog.